Back to School Program Human Services Department

Human Services Department

Back to School Program
Dear Parent or Guardian,

With the last day of the school year just behind us, the first day of the new school year is already fast approaching. The Department of Human Services wanted to inform you of our Back- to-School Program, which helps families by providing school supplies and assistance to purchase other back to school necessities.

If you or your household currently participates in the Town of Mansfield Fee Waiver Program, you automatically qualify for the Back to School Program and do not need to submit additional information with the attached application. If you do not participate in the Fee Waiver Program, eligibility requirements include the following:
- You and your household have been Mansfield residents for at least 3 months prior to the date of application (proof of residency due with application).
- You and your household meet the following income guidelines (60% SMI Proof of income due with application).
If you would like to participate, please fill out the this application by:

August 1st, 2025

Applications can be submitted online, and mailed. Please mail in or drop off additional documentation at:

Human Services Department

303 Maple Rd.

Mansfield, CT 06268

They can also be placed in the secure lock box located outside of the entrance to the Human Services office or emailed to human.services@mansfieldct.org. Applicants will be contacted by August 7th, 2025 with additional program details. Applications received after August 1ˢᵗ, 2025 will not be eligible for assistance. If you have any questions, please feel free to call The Mansfield Human Services Department at 860-429-3315.

Sincerely,

The Human Services Staff

Back to School Program Application

Human Services Department
Name of Parent or Guardian:*
Phone*
Format: (000) 000-0000.
Email*
example@example.com
Address*

Address

Street Address Line 2

CityState / Province

Zip Code
I/my household is currently on the 2025-2026 Town of Mansfield Fee Reduction program and qualify for the Back to School program.I/my household meets the residency and income guidelines eligibility outlined in the attached letter.
My current annual gross income from all sources is
Please enclose ALL of the following with this application:
- Proof of Residency. Applicants must reside in Mansfield for more than three months prior to the date of application.
- Three (3) most recent pay stubs for all income earners in the household.
- Copy of other sources of income (if applicable) i.e.: Social Security, Unemployment, Workman's Comp, SSDI, Veterans Benefits, SAGA, TANF, Child Support, etc.
- Additional considerations and factors you wish to be known in determining your eligibility.

CHILDREN RESIDING IN HOUSEHOLD ENTERING GRADES K-12 IN FALL OF 2025*

Rows	Name	Relationship	Date of Birth	School & Grade in Fall 2025
1
2
3
4
5
6
7
8

Please indicate the items that you would like, with the # of each item.

We will do our best to supply what we can but cannot guarantee all items.
Pens:
Pencils:
Pencil Pouch:
Markers:
Crayons (24 pack):
Colored Pencils:
Pocket Folders:
Erasers:
Wide ruled notebook:
College Ruled Notebook:
1/2 inch Binders
1 inch binders
Pencil Sharpener:
WalmartKohlsOld NavyTJ MaxStaplesTarget
Please upload supporting documents

Cancelof
I hereby certify that the information supplied is accurate to the best of my ability: Applicant Signature*

Clear
Date

MonthDayYear
Date
Mansfield Human Services I 303 Maple Road, Mansfield, CT 06268 I 860.429.3315 I mansfieldct.gov
Should be Empty:

Human Services Department

Back to School Program Application